Hospital Name OUR LADY OF MERCY MEDICAL CENTER

PFI # 1168

Revised: 7/02

Complaints:

Complaint Information: 2001
Complaint Investigations Completed: 10
Complaints with Statements of Deficiencies (SOD) issued: 5
% of Complaints with SODs Issued 50%
Regional % of Complaints with SODs issued: 38.5%

Areas Cited:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted
04/05/01 405.10 Medical Records - General Requirements 07/06/01
08/01/01 405.04 Medical Staff - Medical Staff Accountability 12/03/01
08/01/01 405.06 Quality Assurance Program 12/03/01
08/01/01 405.09 Admission/Discharge - Discharge 12/03/01
08/13/01 405.04 Medical Staff - Medical Staff Accountability  
08/13/01 405.06 Quality Assurance Program  
08/13/01 405.19 Emergency Services  
10/03/01 405.06 Quality Assurance Program 11/14/01
10/03/01 405.10 Medical Records - General Requirements 11/14/01
10/31/01 405.04 Medical Staff - Medical Staff Accountability 12/18/01
10/31/01 405.05 Nursing Services - Delivery of Services 12/18/01
10/31/01 405.06 Quality Assurance Program 12/18/01
10/31/01 405.10 Medical Records - Content 12/18/01
10/31/01 405.23 Food and Dietetic Services - General 12/18/01

Areas Cited as a Result of Surveys:

Date of Survey Type Areas Cited: Date Plan of Correction Accepted
05/15/01 702.02 Housekeeping 08/09/01
05/15/01 751.05 Operating Policies and Procedures 08/09/01
05/15/01 751.06 Personnel 08/09/01

Most Recent Survey Date:

Areas Cited as a Result of Incident Investigations:

SOD Date Regulatory Citation Areas Cited: Date Plan of Correction Accepted